NIDHI PRAYAS Programme of Department of Science and Technology, Government of India National Science and Technology Entrepreneurship Board (NSTEDB)

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1 Note: This form is for reference purpose only. DO NOT FILL AND SUBMIT THIS FORM. Link to the online application form is provided at the bottom of the NIDHI PRAYAS section of STP website NIDHI PRAYAS Programme of Department of Science and Technology, Government of India National Science and Technology Entrepreneurship Board (NSTEDB) PRAYAS - Individual Innovator Application form Application Ref no (To be given by PRAYAS Centre) Latest Photo (not less than 6 months) 1. Title of the proposed project: 2. Applicant Details: a. Name of the applicant: b. Father s name/husband s name: c. Date of Birth: (dd/mm/yyyy) d. ID: e. Mobile Number: f. Landline Number: g. Gender: h. Educational Qualification: i. Category (General/SC/ST/OBC): j. Address : (Please enclose residence certificate issued by Sub-Divisional Magistrate(SDM)/District Magistrate(DM) or a copy of ration card or any other document regarding proof of Residence) Postal Address Permanent Address

2 k. Profession of the Applicant: l. Name & Address of the Institution/Organization: (For Students and working Innovator, No Objection Certificate from Head of Institute /Organization is required) m. Annual Income of the applicant: ( attach a copy of the latest Income Tax Returns filed) n. PAN Card no (mandatory): o. Aadhaar No (mandatory): p. Team Member Details (NOTE: If no team members, kindly mention NA in column Name) Sr No. Name Aadhar No. Pan Card no. Gender Contact -id Qualification 3. Brief description of the idea highlighting innovative element. (Please use a separate sheet) 4. (a) Status of work already carried out (if any) such as. Please tick as applicable. participation in competition making a model provisional application for patent paper presentations publication

3 college project Any other (b) Science and working principle behind the idea (c) Final outcome/deliverable of the project (d) Who would be the beneficiary of this innovation and why? (Please use a separate sheet) 5. Proposed costs and time frame Sr.No Items 1. Outsourcing Charges for R&D/Design Engg/Consultancy/Testing/Expert cost 2. Raw material/ Consumables/Spares 3. Fabrication /Synthesis charges of working model or process 4. Business Travel and Event participation Fees (Ceiling 10% of approved project cost) 5. Patent filing Cost (PCT- Ceiling 10% of approved project cost) 6. Contingency - (Ceiling 10% of approved project cost) Project Cost Own Share PRAYAS support sought Project period in months: (Not more than 18 months) 6. Activity details/work plan Sr.No Activities Monitorable Milestones Duration (months)

4 7. Have you received financial support / award for your present work from any other sources? (if so, please furnish details) 8. Essential Criteria Applicant Confirms that he/she has not been a recipient of any NIDHI-PRAYAS or similar support previously for the same innovative concept as proposed in this form. NIDHI- PRAYAS can be used only once. Applicant is planning to pursue NIDHI- PRAYAS full time with no other concurrent commitments Applicant confirms that he/she is fully committed to work towards the prototype development for which the support is being sought and should not treat this as a stop gap arrangement to support any other pursuits Applicant has or is planning to register for the pre incubation or incubation program at the TBI for the entire duration of PRAYAS support Applicant confirms that if selected for NIDHI- PRAYAS, then they (applicant and their team members) will avail support for their project from only one PRAYAS Centre. If the applicant is found seeking NIDHI-PRAYAS support for the same idea from two different PCs, then the PC reserves right to discontinue the PRAYAS support and appropriate action will be taken on the applicant. Yes / No

5 Applicant confirms that they will not avail the funding support in parallel for both the schemes i.e NIDHI-PRAYAS and NIDHI - EIR from the same or different centers. 9. Declaration: I declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. If any information is found false or incorrect, my candidature will stand cancelled and all my claims will be forfeited. I have not received any financial assistance for the present proposal from any other agency. Place: Signature of the applicant Date: